Medicine case presentation

Hello, Mushfequa here. 

I would like to present a general medicine case as a part of my daily learning log. 

A 42 year old male patient came to the the medicine opd on 13th May 2020 with the complaints of 

-abdominal distension since 15 days which was gradually increasing in size. 

-pedal edema upto the thigh since 10 days which is considerably reduced upon taking rest. 

- c/o mass per rectum on passing stools 

No history of constipation, melena, vomiting, belching, decreased urine output, burning micturition, fever, shortness of breath and pain abdomen. 

PAST HISTORY

Not a known case of diabetes mellitus, hypertension, tuberculosis, asthma, cardiovascular disorders. 

He is a chronic alcoholic with consumption of 180ml of whisky per day since 20 years, stopped drinking for the past 2 months. 

He has a history of jaundice 5 years back.

EXAMINATION 

On physical examination there is presence of pallor, icterus and pedal edema upto thigh which is pitting in nature. 

No cyanosis and lymphadenopathy. 

At the time of admission 

temperature - 99°F

Pulse rate - 102bpm

Blood pressure - 120/80

Weight - 71kgs

  

Jaundice - present 

No gynaecomastia 

No spider naevi

Palmar erythema - absent 

Clubbing - present 

Fetor hepaticus - absent 

Dupyetren's contraction - absent 

Flapping tremors - absent 

 

ABDOMEN - 

Inspection: straie, bruising, scars- absent 

Distension appears tense with flanks full 

Palpation : no tenderness

Abdominal girth - 100cms  

Percussion :

Shifting dullness : present 

Auscultation : bowel sounds - present 

INVESTIGATIONS

Ultrasonogaraphy 

 

Ascitic tap - was done by my Co - intern for diagnostic purposes. 

 

DIAGNOSIS 

Decompensated liver disease 

TREATMENT 

Salt and water restriction

Inj. Lasix 40mg bd 

T. Spironolactone 50mg bd

Syp. Lactulose 50mg bd

Inj vit k 10 mg s.c

Inj pantop 40mg 

High protein diet 

I/O monitoring 

Daily abdominal girth and weight monitoring 

FOLLOW UP of the patient 

14th May 2020 - before the ascitic tap  abdominal girth :100cms

Weight:71kgs

15th may 2020 - 

Abdominal girth: 94cms 

Weight : 69kgs

16th may 2020 - 

Abdominal girth: 92cms

Weight: 65kgs 

NEET RELATED PREPARATION 

Anti-arrhythmic drugs